Corporate Compliance

Note from the instructor: CMS issues guidance to contractors on alternate medical documentation authentication

Medicare Insider, August 4, 2015

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This week’s note from the instructor is written by Judith L. Kares, JD, regulatory specialist for HCPro.

In order to be covered, Medicare requires the author to authenticate most services provided to or ordered for a beneficiary. An essential component of medical review includes contractor verification that relevant authentication requirements for specific services have been met. In a recent transmittal, R604PI, CMS identified several forms of alternate medical documentation that contractors may rely upon during the review process.

General method of authentication

The usual method of authentication is a handwritten or electronic signature by the practitioner who provided or ordered the services. Stamped signatures are generally not acceptable. There are several specific exceptions to the usual authentication method, however, including the following:

  • Facsimiles of original written or electronic signatures for certification of terminal illness for hospice;
  • Use of a rubber stamp in the case of an author with a physical disability that can provide proof to a contractor of his or her inability to sign his or her signature due to that disability; and
  • Certain services for which a signed order is not required.
    • Example: Orders for some clinical diagnostic tests are not required to be signed. In that case, however, there must be medical documentation (e.g., a progress note) by the treating physician that he or she intended the clinical diagnostic test be performed, which the author must authenticate via a handwritten or electronic signature.

In many cases, there may also be other regulations and/or CMS instructions regarding conditions of payment related to signatures. For medical review purposes, if the relevant regulation, NCD, LCD, and/or CMS manuals are silent on whether the signature needs to be legible or present and the signature is illegible/missing, the contractor should follow the updated guidelines set out in CMS’ recent transmittal to determine the identity and credentials of the signator. In cases where the relevant regulation, NCD, LCD, and/or CMS manuals have specific signature requirements, those requirements take precedence over general guidelines.

General guidelines when signature is illegible/missing

Before getting into specifics, we need to identify the Medicare contractors subject to these authentication rules, which include the following:

  • MACs;
  • Comprehensive Error Rate Testing Contractors (CERT);
  • Zone Program Integrity Contractors (ZPIC); and
  • Supplemental Medical Review Contractors (SMRC).

Please note that these rules do not apply to Recovery Auditors.

Finally, there are two additional points that need to be made:

  • First, if MAC and CERT reviewers find reasons for denial unrelated to signature requirements, the reviewer need not proceed to signature authentication; and
  • Second, practitioners should not add late signatures to the medical record (beyond the short delay that occurs during the transcription process), but instead should make use of the signature authentication process set out below.

The following is a summary of the general signature authentication process that contractors should follow:

Handwritten signature: mark or sign by an individual on a document signifying knowledge, approval, acceptance, or obligation.

  • If the signature is illegible, MACs, ZPICs, SMRCs, and CERT contractors should consider evidence in a signature log, attestation statement, or other documentation submitted to determine the identity of the author of a medical record entry.
  • If the signature is missing from an order, MACs, SMRCs, and CERT contractors should disregard the order during the review of the claim (e.g., act as if it had not been submitted).
  • If the signature is missing from any other medical documentation (other than an order), MACs, SMRCs, and CERT contractors should accept a signature attestation from the author of the medical record entry.

Signature log: list of typed or printed name of author associated with initials or illegible signature.

  • May be included with page on which initials or signature appear or in a separate document.
  • Preferable, but not required, for practitioners to include credentials.
  • Reviewers should consider all logs, regardless of when created.

Signature attestation statement: statement signed and dated by the author of the medical record entry containing sufficient information to identify the beneficiary.

  • CMS currently neither requires nor instructs providers to use a certain form or format.
  • General request for signature attestation is considered a non-standardized follow-up question to providers, but no standard format should be provided to them.
  • Providers may use the following format, however:
    • “I, _____[print full name of the physician/practitioner]___, hereby attest that the medical record entry for _____[date of service]___ accurately reflects signatures/notations that I made in my capacity as _____[insert provider credentials (e.g., MD)]__when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.”
  • MACs and CERT contractors should not consider attestation statements where there is no associated medical record entry.
  • Reviewers should not consider attestation statements from someone other than the author of the medical record entry in question.
  • Reviewers should consider all attestations regardless of the date created, unless regulations or policy indicate a signature must be in place prior to a given event or a given date.

Signature guidelines

Contractors should follow these additional guidelines in determining whether to consider the signature requirements met:

  • In the situations where the guidelines indicate “signature requirements met,” the reviewer should consider the entry.
  • In situations where the guidelines indicate “contact billing provider and ask a non-standardized follow up question,” the reviewer should contact the person or organization that billed the claim and ask if the billing entity would like to submit an attestation statement or signature log within 20 calendar days, beginning on the date of the telephone contact or the date the request letter is received by the provider. If the biller submits a signature log or attestation, the reviewer should consider the contents of the medical record entry.
  • In cases where a reviewer has requested a signature attestation or log, the time for completing the review is extended by 15 days, starting on the date of receipt of the signature attestation or log.
  • The MACs, CERT contractors, and ZPICs should document all contacts with the provider and/or other efforts to authenticate the signature.
  • The MACs, CERT contractors, and ZPICs should NOT contact the biller when the claim should be denied for reasons unrelated to the signature requirement.

Electronic signatures

CMS offered some words of caution to providers regarding the use of electronic signatures. In particular, they noted the potential for misuse or abuse of such mechanisms and the need for adequate administrative procedures that comply with recognized laws and other standards. CMS followed up with a reminder that the individual whose name is on the alternate signature method and the provider bear mutual responsibility for the authenticity of the information for which an attestation has been provided.

Review of authentication policies

Hospitals are encouraged to study these most recent authentication guidelines, along with their current related policies, to ensure compliance upon medical review.

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